IBD Acute Ulcerative Colitis Medical ... - Seattle Children's

IBD Acute Ulcerative Colitis Medical Management v.2.0 Executive Summary

ED Acute Ulcerative Colitis

Test Your Knowledge

Explanation of Evidence Ratings Summary of Version Changes

Citation Information ED Inclusion Criteria · Known ulcerative colitis

Exclusion Criteria · Toxic megacolon · Known active infection including CMV, C difficile, or TB · Crohn’s disease · Gastrointestinal (GI) perforation

Initial Workup for Acute Ulcerative Colitis (ED Ulcerative Colitis) · Clinical assessment, labs, stool · Nurse to complete PUCAI score tool · Consider abdominal X-ray and surgical consult for symptoms such as severe pain, abdominal distention, guarding or rigidity, fever (>38.5C), shock

· · · · ·

Assess for dehydration Assess pain Withhold 5-ASA, 6-mercaptopurine, and azathioprine Avoid routine use of opiates or NSAIDs NPO except for medications

Consider exclusion criteria

Toxic Megacolon, Active CMV, C diffcile or Tb?

Yes

Off Pathway

No, consider admit criteria

Admit Criteria · PUCAI >65 OR · 6 or more bloody bowel movements/day AND one of the following: tachycardia, fever, anemia, elevated ESR OR · Dehydration, unable to take oral medications or oral resuscitation

Discharge Instructions Discharge

· ED Ulcerative Colitis handout · Follow-up plan as discussed with GI

Admit

First-line Treatment Acute Severe Ulcerative (ED Ulcerative Colitis) First-linefor Treatment for Acute SevereColitis Ulcerative Colitis · Discuss treatment plan with GI · First-line treatment methylPREDNISolone 1.5mg/kg IV max 60mg daily 0800 (may give first dose in ED, if first dose given after midnight give second dose the following day at 0800) · Patients established on steroids: continue and add stress dose · Pain management · Antibiotics if at risk for C. difficile · For patients who have received outpatient treatment (6-mercaptopurine, azathioprine, infliximab, course of oral steroids) discuss alternate next steps with GI

To Inpatient Treatment For questions concerning this pathway, contact: [email protected] © 2015, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Last Updated: June 2015 Next Expected Review: July 2015

IBD Acute Severe Ulcerative Colitis Medical Management v.2.0 Executive Summary

Explanation of Evidence Ratings

Inpatient Acute Severe Ulcerative Colitis

Test Your Knowledge

Summary of Version Changes

Citation Information

!

Inclusion Criteria

Change in diagnosis; toxic megacolon; active CMV, C difficile, or TB

Known ulcerative colitis with Acute Severe Colitis defined as: · Pediatric Ulcerative Colitis Activity Index (PUCAI) >65 OR · 6 or more bloody bowel movements/day AND one of the following: tachycardia, fever, anemia, elevated ESR · Dehydration, unable to take oral medications or oral resucitation

Exclusion Criteria · · · ·

Toxic megacolon Known active infection including CMV; C difficile, or TB Crohn’s disease Gastrointestinal (GI) perforation

Off Pathway

Day 1-5 – Evaluate PUCAI and labs, monitor progress daily Provide Education Ulcerative Colitis: Treating your Child in the Hospital PE1506 Establish nutrition plan/support Assess thromboembolism risk, consider prophylaxis PUCAI 45

PUCAI 35-45 · Continue same

· Repeat stool test for C. difficile · Confirm TB status · Consult surgeons and stoma therapist · Consider second-line therapy with steroid taper · PUCAI >65 consider colectomy

Proceed to Discharge

Day 3 · Order nutrition consult (if not already performed) · Schedule Sigmoidoscopy. If biopsy CMV positive, consult infectious disease specialist for therapy.

Day 6-10 – Evaluate PUCAI and labs, monitor progress daily PUCAI

Establish nutrition plan/support PUCAI 65 · Start second-line therapy with steroid taper · Strongly consider colectomy with any significant deterioration

Day 11-14 – Evaluate PUCAI and labs daily Establish nutrition plan/support PUCAI 65 · Colectomy

Go to Discharge

For questions concerning this pathway, contact: [email protected] © 2015, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer


IBD Acute Severe Ulcerative Colitis Medical Management v.2.0 Executive Summary

DISCHARGE PLANNING

Test Your Knowledge

Explanation of Evidence Ratings Summary of Version Changes

Citation Information Definitions 5-ASA, 5-aminosalicylic acid ASC, acute severe colitis CMV, cytomegalovirus NPO, nothing by mouth PUCAI, pediatric ulcerative colitis activity index UC, ulcerative colitis of live measures

PUCAI 4 hours, rectal bleeding with most bowel movements for 2 days, diarrhea that causes child to awaken at night, to not drink enough liquid, or restricts activity, or for other concerns.

Return to ED Management

Return to Inpatient Management

For questions concerning this pathway, contact: [email protected] © 2015, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer


Objective 1: Inclusion & Exclusion Criteria

ED Inclusion Criteria

ASC patients can present to ED or directly to inpatient ward

· Known ulcerative colitis

Exclusion Criteria · Toxic megacolon · Known active infection incuding CMV, C difficile, or TB · Crohn’s disease · Gastrointestinal (GI) perforation

Admit Criteria · PUCAI >65 OR · 6 or more bloody bowel movements/day AND one of the following: tachycardia, fever, anemia, elevated ESR OR · Dehydration, unable to take oral medications or oral resuscitation

The algorithm only applies to patients with known UC • Exclude acute infections precluding antiinflammatory agent use & toxic megacolon • Review ED admission criteria • Based on signs & symptoms and pediatric UC activity index

[Consensus Guideline (Turner, 2011)]



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Objective 4: Medical therapy 1st Line First-line therapy Methylprednisolone 1.5mg/kg/day max 60mg First dose in ED/on admission, subsequent daily 0800 dose Patients already on steroids: continue and add stress dose [Consensus Guideline (Turner, 2011) with local expert opinion]

Acid Blockers • Standard prophylaxis against gastrointestinal bleeding is

not recommended • Possible risk of C difficile • Risk of hospital acquired pneumonia [ Low quality] (Chaibou 1998, Herzig 2006, HernandezDiaz 2000, Hyams 2006, FDA, Reveiz 2010, Turco 2010, Wilson 2010)

Antibiotics * Turco 2009 • Routine antibiotic use is not recommended ** Herzig 2009

• Consider antibiotic therapy for C diff if at risk o

Antibiotic use 3 days to 3 months prior to colitis symptoms

o

Prior recent history of C diff infection

• May start empiric antibiotics pending results. • Mild to moderate symptoms: oral metronidazole • Severe symptoms but tolerating oral intake: oral Vancomycin • If NPO: IV metronidazole


[Consensus Guideline (Turner, 2011) with local expert opinion]


Objective 1: Algorithm Inclusion & Exclusion Criteria

Inclusion Criteria Known ulcerative colitis with Acute Severe Colitis defined as: · Pediatric Ulcerative Colitis Activity Index (PUCAI) >65 OR · 6 or more bloody bowel movements/day AND one of the following: tachycardia, fever, anemia, elevated ESR · Dehydration, unable to take oral medications or oral resucitation

• Anti-inflammatory agents may be contraindicated in active infections • Toxic megacolon and GI perforation are medical and surgical emergencies

Exclusion Criteria · · · ·

Toxic megacolon Known active infection including CMV; C difficile, or TB Crohn’s disease Gastrointestinal (GI) perforation

Ulcerative Colitis - Acute Severe Colitis: Definition [Consensus Guideline (Turner, 2011)]

• •

Patients with severe Ulcerative Colitis are generally hospitalized Proposed criteria for diagnosis: o o

>6 bowel movements with blood daily One of the following – tachycardia (>90 bpm) – temperature >37.8 °C – anemia (hemoglobin 30 mm/h)

Travis et al. J Crohn Colitis 2008;2:24–62 Turner et al. Gastroenterol 2007;133:423–32

Severely inflamed colon

Objective 3: Toxic megacolon • Medical/surgical emergency • Suspect in patients with: •

Symptoms/signs: severe pain, abdominal distention, altered level of consciousness, guarding or rigidity

•

Systemic toxicity: fever, tachycardia, dehydration, electrolyte disturbance (esp hypokalemia), or shock

•

Radiographic evidence of colon dilatation •

>=56mm or

•

>40mm in patients 8

0 5 10 15

Nocturnal Stools

No Yes

0 10

Stool Consistency

Formed Partially formed Completely unformed

0 5 10

Activity

No limitation Occasional limitation Severe restriction

0 5 10

Pain Rectal Bleeding

Turner et al. Gastroenterology 2007 ; 133 : 423 – 32



Nutrition • If tolerated, oral intake should be continued • Allow GI1 or GI2 diet (low fructose, lactose, residue) • If patient is on opioids • restrict oral intake to clears • restrict sugar and sweetened beverage • Nutrition consult should be done by day 3 of admission • Malnutrition and anemia are associated with increased post-op morbidity • Oral intake should be restricted in patients with toxic megacolon and impending surgery [Consensus Guideline (Turner, 2011) with local expert opinion]


Turner 2011


Pain Control • Pain out of proportion with disease severity should be

taken seriously and promptly lead to exclusion of TMC and bowel perforation • Use relaxation techniques, hot packs, and acetaminophen • Consider benzodiazepines (lorazepam) • Consider nalbuphine per formulary


Pain Control • When to consult pain team • Uncontrolled episodic pain that may require PCA • Patients on baseline opioids at presentation without adequate control • Pre-surgery (even if well-managed) • If requiring >4 doses of nalbuphine per 24 hours

[Expert Opinion (E)]



Steroid taper after starting 2nd line therapy • Steroid taper must be initiated to reduce immune suppression • Taper dose by 20% every 5 days [Expert Opinion (E)]

Go to 2nd Line Therapy Page 2


IBD Acute Severe Ulcerative Colitis Medical Management v1.3 Second-line Therapy in Pediatric Corticosteroid-Refractory Ulcerative Colitis

Initial Dosing

Trough Drug Levels

Tests Before Treatment

Infliximab

Tacrolimus

5mg/kg over 2-4h; subsequent doses given 2 weeks and 6 weeks after the initial infusion. Some centers utilize higher doses (10mg/kg), or infuse the second dose after 7-10 days.

0.1mg/kg/dose orally b.i.d. Stop medication after 3-4 months.

Not indicated.

Aim initially for 10-15ng/ml, and then 510ng/ml, once remission achieved (for timing see below).

Documentation of negative tuberculosis testing and chest Xray; consider varicella hepatitis B and C serology in endemic areas.

Measure blood pressure and blood tests: creatinine, glucose, electrolytes, liver profile; test and treat hypomagnesemia and hypocholesterolemia to decrease the risk of neurotoxicity (more with cyclosporine).

Infusion reactions, increased infection rate, rare opportunistic infections.

Hypertension, hyperglycemia, hypomagnesemia, immune suppression, azotemia (dose dependent), seizures (dose and hypocholesterolemia dependent), hirsutism (more with cyclosporine), tremor (more with tacrolimus); erythromycin, ketoconazole, and grapefruit juice can increase cyclosporine and tacrolimus levels.

Frequent assessment of vital signs during infusion.

Monitor every other day during induction, weekly for the first month, and then monthly: drug levels (starting after third dose), creatinine, glucose, electrolytes (including magnesium), lipid levels, blood pressure, and neurological symptoms. Consider: measure creatinine clearance at baseline and initiate Pneumocystis pneumonia prophylaxis.

Main Toxicity

Monitor Toxicity

Return to 2nd Line Therapy Page 1



Discharge Medication Considerations • At discharge • When switching from IV methylprednisolone to oral prednisone, dose should be increased by 20% to yield biologically equivalent dose • Steroid maximum dose will be continued for 2-4 weeks total then taper will be started 2-3 weeks after initiation by 5 mg weekly


Discharge Medication Considerations • If starting azathioprine: • best delayed 2 weeks after discharge

• If tacrolimus used: • azathioprine best delayed till prednisone